Healthcare Provider Details

I. General information

NPI: 1992396188
Provider Name (Legal Business Name): MISS MAE HELEN CUSACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2021
Last Update Date: 09/21/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

673 SAN JOSE AVE
SAN FRANCISCO CA
94110-4914
US

IV. Provider business mailing address

673 SAN JOSE AVE
SAN FRANCISCO CA
94110-4914
US

V. Phone/Fax

Practice location:
  • Phone: 415-282-3769
  • Fax:
Mailing address:
  • Phone: 415-282-3769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number2080P0008X
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: